Failure to Resubmit PASRR After New Antipsychotic Medication Initiation
Penalty
Summary
The facility failed to resubmit a Preadmission Screening and Resident Review (PASRR) after a resident with a history of serious mental illness was prescribed a new antipsychotic medication. According to facility policy and federal requirements, any change in a resident's symptoms, diagnosis, or medication related to serious mental illness necessitates a new PASRR Level 1 screening. The medical record showed that the resident, who had diagnoses including Bipolar Disorder, Schizophrenia, and Anxiety Disorder, was started on Haloperidol for severe depressive symptoms with psychotic features. Despite this significant medication change, there was no documentation of a new PASRR submission following the addition of Haloperidol. The resident had a history of severe cognitive impairment, as indicated by low BIMS scores, and was receiving multiple psychotropic medications. The last PASRR on file was dated several years prior to the medication change. During an interview, the Admissions Coordinator confirmed awareness of the requirement to resubmit PASRRs upon such changes and acknowledged that a new PASRR had not been completed for this resident since the last one on record. This lapse was identified through policy review, medical record review, and staff interview.